Author
Mark P. Brady, PA-C
Chief Physician Assistant
Department of Emergency Medicine
Cambridge Hospital
Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Richard S. Krause, MD
Senior Faculty
Department of Emergency Medicine
State University of New York at Buffalo School of Medicine
Buffalo, New York
Disclosure: Richard S. Krause, MD, has disclosed no relevant financial relationships.
Running is an excellent form of exercise, but it is considered a high-impact sport. When a runner's foot hits the ground, forces equal to 3 times body weight are generated. The resulting stress can lead to injuries over time. Many running injuries can be prevented with proper conditioning, training, and footwear selection. Plantar fasciitis is the most common cause of heel pain in runners and accounts for 10% of running-related injuries. Thought to be caused by repetitive microtrauma, an inflamed plantar fascia can cause severe pain when walking or running. The diagnosis may usually be made clinically. Seen on MRI, thickening of the plantar fascia (arrow) with edema in the fascia and surrounding soft tissues are diagnostic. Treatment of plantar fasciitis begins with rest, icing, and anti-inflammatory medications.
The Achilles tendon is the strongest tendon in the body but also the most commonly injured. The tendon connects the calf muscles to the calcaneus. Achilles tendon injury often develops after sudden changes in activity or training level, overuse, use of inappropriate footwear, or training on poor running surfaces. During running, forces equaling 10 times the body weight have been measured within the tendon. Achilles tendonitis, the most common injury, causes tendon swelling and burning pain. Tendonitis usually requires only ice and rest. Greater forces may cause a partial or complete rupture. Treatment of Achilles tendon rupture requires complete immobilization and often surgery (shown).
Calcaneal (heel) spurs (arrow) are a common cause of chronic heel pain. They are a result of repetitive stress at the heel, resulting in calcification of the soft tissue attachments, creating a bone spur. Approximately 70% of patients who have plantar fasciitis also have heel spurs. Once thought to be located at the insertion of the plantar fascia, cadaver studies have shown that the heel spur is actually located at the insertion point of the short flexor muscles of the toes. Treatment consists of rest, ice, stretching exercises, and anti-inflammatory medications. Orthotic devices (shown) inserted in running shoes can often relieve pain by adding support to the heel and helping to distribute weight during movement. Image on left courtesy of Wikipedia Commons.
Ankle sprains are the most common foot and ankle injuries. They are often caused by running on an uneven surface. Approximately 85% of all ankle injuries are sprains. Decision rules may be used to determine whether x-rays are needed. Inversion injuries damaging the lateral ligaments are the cause of 85% of sprains. A comparison of the contralateral foot/ankle for symmetry, deformity, ecchymosis (arrow), edema, tenderness, or crepitus should be included in the physical examination. Treatment to improve range of motion and strength of the ankle is as essential as reduction of pain.
Management of an acute ankle sprain consists of protection using an air splint or hook and loop brace (shown), rest, ice, compression with elastic bandage, elevation, and support (PRICES) and is meant to minimize swelling and allow the patient to begin walking immediately. Because chronic symptoms develop in 40% of patients with untreated or misdiagnosed ankle injuries, early diagnosis and treatment with rehabilitation is imperative.
The hamstrings are a group of 3 muscles that run along the back of the thigh from the ischial tuberosity to the posterior tibia. This muscle group provides leg extension and knee flexion. The hamstring muscles are very susceptible to tears and strains from excessive stretch. Athletes particularly at risk for hamstring injuries are competitors involved in sports that require a high degree of speed, power, and agility and involve sprinting with sudden stops and starts. A consistent program of stretching and strengthening exercises can help prevent hamstring injuries. Physical examination findings may be absent in many hamstring injuries but include swelling, ecchymosis (shown), and muscle contraction in severe cases. Image courtesy of Wikipedia Commons.
Patellofemoral syndrome (PFS), also known as chondromalacia patella or runner's knee, is the most common overuse injury among runners and can result in pain under or around the patella as well as a grating or grinding sensation during extension of the knee. Much controversy exists regarding the causes of patellofemoral syndrome. However, most specialists agree that PFS is caused by overuse, trauma, or an abnormal alignment of the patella and femur, causing in damage to the underlying cartilage, and resulting in irregularities, fissuring (arrows), and marked thinning of patellar cartilage. Conservative management concentrated on improving strength and flexibility while controlling symptoms with rest, ice, and anti-inflammatory medications is successful in 80% of cases of PFS.
Patellar subluxation occurs when the patella rides off center and shifts from its normal midline trochlear grove. Patellar subluxation is thought to be associated with multiple factors, including a shallow patellofemoral groove (trochlea), a wide pelvis, and abnormalities in gait. Patellar subluxation is common in adolescents and may be asymptomatic or cause pain with activity. Patellar dislocation occurs if the patella is pulled completely out of the trochlear groove (shown).
Most patellar dislocations occur laterally, resulting in a torn medial patellofemoral ligament (MPFL). This ligament usually secures the patella to the medial aspect of the knee. Often an MPFL does not heal with the proper tension, which can result in recurrent patellar dislocations. Patellar relocation is performed by placing force in the patellar while slowly extending the knee (shown). This will allow the patella to lift over the femoral condyle. If conservative management fails, a surgical procedure known as a "lateral release" may be performed to reduce the tension of the lateral ligaments on the patella.
Patellar tendonitis, also known as jumper's knee, is the result of overtraining, playing on hard surfaces, and repeated jumping. The patellar tendon attaches the inferior aspect of the patella to the anterior tibia and extends the knee when the quadriceps muscles contract. The proximal patellar tendon is the area most commonly affected. Avoiding activities that aggravate the problem is the most important first step in treatment, followed by conservative management with rest, ice, compression, and elevation. The image on the left shows a normal MRI of the knee. The image on the right demonstrates a focal area of abnormal increased signal intensity in the proximal portion of the patellar tendon at the bone-tendon insertion (arrow). Image on left courtesy of Wikipedia Commons.
The quadriceps tendon attaches to the superior aspect of the patella and, together with the quadriceps muscles of the thigh and the patellar ligament, allows knee extension. Strains and overuse injuries to the quadriceps tendon are common and result in miscroscopic tears and inflammation. Following a quadriceps tendon injury, patients may or may not be able to ambulate. Tendon rupture can be manifested as abnormal thickening of the tendon (left image) or as complete, revealing retraction of the quadriceps tendon (right image). Individuals with a complete tear will be unable to extend the knee and often have a palpable defect at the site of tendon rupture. Initial management consists of immobilization, crutches, rest, ice, and elevation. Complete tendon rupture requires surgical repair.
The menisci consist of 2 C-shaped pieces of cartilage that act as cushions between bones in the medial and lateral knee. Meniscal cartilage tears usually occur with movements that forcefully rotate the knee while bearing weight, often when an athlete quickly twists or rotates the upper leg while the foot is firmly planted. An injured or torn meniscus may cause pain and swelling. Frequently, an injury to the meniscus causes an audible click, and the knee may lock or feel weak. This proton density weighted MRI shows a full-thickness tear through the base of the medial meniscus (arrow). If the meniscus injury is small, these symptoms may resolve over time; more serious meniscus injuries may require surgical repair.
The iliotibial band (ITB) is a ligament that runs along the outside of the thigh from the iliac crest to the lateral tibia and helps stabilize the knee and hip. ITB syndrome occurs when the ligament rubs over the bones on the outside of the knee and becomes inflamed, causing pain. ITB syndrome may be secondary to blunt trauma but is usually caused by overuse, specifically with running. ITB syndrome can cause localized pain at the lateral aspect of the knee (wide arrow) or may radiate up the side of the thigh (small arrows). ITB syndrome may resolve with reduced activity and stretching followed by muscle-strengthening exercises.
The cause of exercise-induced compartment syndrome or chronic exertional compartment syndrome (CECS) is not fully understood. During exercise, increased blood flow to the muscles increases their volume. If the fascial sheath is unable to accommodate the increase in volume, compartment pressure may increase. This can disrupt blood flow and cause painful muscle ischemia. Patients often describe numbness and tingling as well as muscle tightness, most often in the anterior leg. CECS usually occurs in well-conditioned athletes younger than 40 years, in those who significantly increase their training, or in inactive patients who initiate rigorous training. Diagnosis is made by measuring the pressure within the affected muscle compartments (shown). Conservative management is often unsuccessful in patients diagnosed with CECS, and surgery with fasciotomy is usually required. Acute compartment syndrome usually occurs with direct muscle trauma and requires immediate surgery.
Stress fractures are common overuse injuries that develop in up to 15% of runners. Stress fractures of the calcaneus (arrow) are especially common in athletes such as distance runners. Stress fractures are caused by repetitive injury. Pain develops slowly, increasing with activity and intensity and improving with rest. As the stress fracture worsens, pain may become constant. Pain can often be elicited by squeezing the medial and lateral aspects of the heel, as opposed to the plantar aspect of the heel as in plantar fasciitis. Stress fractures are not always visible on x-rays and may only be seen with bone scans or MRI. Surgery is rarely needed, and treatment often consists of minimizing weight bearing with a walking boot or crutches.
There are 2 types of stress fractures: insufficiency and fatigue fractures. Insufficiency fractures occur in abnormal bone under normal force. Fatigue fractures occur in normal bone under extreme force. Fatigue fractures are usually caused by repetitive, new, strenuous activities such as distance running. Most stress fractures of the hip are fatigue fractures and usually involve the femoral neck (arrows). The femoral neck usually withstands significant force even during normal activities like walking. Running triples the stress on the femoral neck. A displaced stress fracture in a young athlete is a serious injury and can lead to avascular necrosis of the hip. Pain is often felt in the groin and may improve with rest. Management may require surgery, depending on the location and type of fracture. Conservative management consists of avoiding bearing on the affected leg.
"Shin splints" refers to a syndrome of pain over the anterior tibia and is not a specific diagnosis. Shin splints are most commonly the result of overuse and can be secondary to stress fractures, exercise-induced compartment syndrome, or medial tibial stress syndrome. Medial tibial stress syndrome, the most common cause, is caused by irritation to the tendons where the tendons attach to bone. Shin splints are commonly seen in athletes who suddenly increase their intensity or duration of training or in marathon runners who have high-demand training levels. Runners may feel a dull, aching pain and tenderness on the inside of their tibia. X-rays may reveal fractures, and bone scans can detect hot areas (arrow) of high bone turnover that can indicate possible stress fractures. Rest, ice, massage, anti-inflammatory medications, and low-impact rehabilitation exercises are often recommended as initial management.
The plica are folds of synovial tissue within the knee joint that develop in the fetus and persist as synovial membranes after birth. Some individuals are prone to irritation and inflammation of the synovial plica tissues. This occurs more frequently medially (arrow) than laterally, and in runners, it is often the result of overuse. The symptoms and knee examination in synovial plica syndrome are similar to those that occur with meniscal tears, patellofemoral syndrome, or patellar tendonitis. This diagnosis can be difficult to make and is often made during athroscopy (inset). Conservative management with rest, ice, anti-inflammatory medications, and occasionally steroid injection usually results in a significant improvement. Persistent symptoms may require surgical removal of the offending plica tissue.
Bursae are synovial-lined sacs that serve as a protective buffer and help facilitate movement of skin, muscle, and tendon over bone. They are located at various joints throughout the body, such as the shoulder, elbow, and knee. Bursitis occurs when one or more of these sacs become inflamed. Prepatellar bursitis is a common cause of pain and swelling on the anterior aspect of the knee. It is most commonly caused by kneeling, which is why it is also called "housemaids knee." Runners are also susceptible, particularly those who fail to stretch and warm up properly, those who increase mileage quickly, or those who train on hills. Symptoms include swelling in front of (prepatellar, shown) or underneath (infrapatellar) the patella, warmth and tenderness, and pain with movement. Image courtesy of Wikipedia Commons.
Patellar bursitis can be diagnosed clinically and is readily seen on MRI, as in this case of prepatellar bursitis with thickening and irregularity of the bursa (arrows).Treatment of bursitis consists of rest, ice, and compression to reduce swelling and anti-inflammatory medications. Persistent swelling may require aspiration of the bursae fluid. If infection occurs, antibiotics are usually recommended. In some cases, the bursae requires surgical removal.
Blisters are a common problem in athletes. They may occur when wearing new shoes or in long distance running events. Foot blisters are rarely serious, but they can be painful and become infected. Preventive measures and recognizing early signs of blister formation can help prevent complications. Foot blisters are caused by friction between the skin and shoes. Lymphatic fluid fills the separating skin layers. Prevention includes shoes that fit correctly, protecting potential hot spots by applying "second skin" and/or taping, keeping feet as dry as possible, changing socks regularly, and using foot powder to help keep the feet dry. Blisters should usually be drained or aspirated with a sterile needle. Swab the blister with alcohol or other antiseptic solution to keep it clean and apply a protective dressing The skin layers will adhere together. Usually within 48 hours blisters are dry enough to expose to the air. Image courtesy of Wikipedia Commons.
Although each patient presents with a unique set of historical risk factors and presenting complaints, a number of general considerations can be made. The most common causes of running injuries are listed. Injuries can usually be prevented with proper rest, avoidance of overtraining, proper hydration and nutrition, replacing shoes every 400-600 miles, adhering to regular training schedules, cross-training, and allowing adequate recovery time. Most mild running injuries will resolve with conservative treatment. However, injury symptoms that persist or are refractory to conservative treatment should be evaluated and treated by a professional.
Author
Mark P. Brady, PA-C
Chief Physician Assistant
Department of Emergency Medicine
Cambridge Hospital
Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P. Brady, PA-C, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Reviewer
Richard S. Krause, MD
Senior Faculty
Department of Emergency Medicine
State University of New York at Buffalo School of Medicine
Buffalo, New York
Disclosure: Richard S. Krause, MD, has disclosed no relevant financial relationships.
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